4 Simple Rehab Program Templates

Single leg opposite arm row, an upper body “pulling” exercise which demands stance leg and trunk stability and control.

[Note: This is an expanded form of an excerpt from the manual from my workshop Introduction to Kettlebells for Rehabilitation, which I developed and teach with exercise sciencist and personal trainer James Ross. As a brief background, we categorised the exercises into either push/pull for the upper/lower/core. The concepts below can be applied however you categorise movement for programming purposes.]

It’s easy to find exercises online.

Whether you search by joint, muscle group, movement pattern, you will find hundreds, if not thousands of examples.

This alone should tell you something: there is no one way to exercise.

In fact, the only two rules for exercise that are anything close to written in concrete are:

  1. On adaptation: start where you are (i.e. your current ability), do what you can (i.e. don’t push too hard too soon) and progress over time (without progress you stop adapting).
  2. On specificity: you have to practice what you want to get better at (i.e. if you want to run faster, you have to practice running faster).

With that said, there are definitely better and worse ways to exercise, regardless of your goals.

Better ways are more efficient, more effective, safer and more enjoyable. Worse ways are the opposite.

When it comes to clinic rehabilitation for musculoskeletal pain, exercise is an important intervention. Increasing evidence is mounting showing that for many orthopaedic/musculoskeletal conditions, a well structured rehabilitation program yields similar outcomes to surgery over the long term.

Please don’t confuse this with me saying exercise is the only intervention required for clinical rehabilitation.

It stands to reason that structuring an exercise program optimally will yield better results.

With that in mind, the following are examples of templates I commonly use when designing exercise rehabilitation programs for clients in practice.

Bare Minimum

This is simply a single movement exercise “program”, which I often utilise when there are many barriers to adherence. It can also serve as a “gateway” to a more comprehensive program in early stage rehab.

I would typically advise 1-3 sets performed to fatigue as a minimal dosage. With a set/rep based approach we can manipulate intensity via the rep range. This can be a good way to develop strength, strength endurance or even speed/power.

Otherwise a time based approach (i.e. try and do as many sets of 5 in 10 minutes as you can). With a time based approach, we are using sub maximal loads and accumulating volume. This can be a good way to develop strength endurance and work capacity.

There are 2 main ways to design this single movement program.

  • Load the painful movement:
    • Pain management via local tissue effects and central inhibitory effects
    • Develop functional capacity in local tissues
    • Enhance physiological buffer zone
  • Load the non-painful movement:
    • Pain management via central inhibitory effects
    • Develop functional capacity systemically
    • Address weakness/limitations
    • Enhance physiological buffer zone

The bare minimum approach can also be used with multiple movements – i.e. one movement each day, performed for the prescribed sets/reps/time. These are then cycled through.

An example of a 3 day cycle might be:

  1. Squat
  2. Push up
  3. Inverted row

Each of which is performed for as many sets of 10 reps as possible in a 10 minute window on consecutive days. After the third day, start the cycle again.

Whichever approach you take, with bare minimum programming, you typically want to use compound movements, as they maximise efficiency. So for lower body, things like squats, lunges, step ups and hip hinge variations reign supreme.

Minimalist

Using two exercises allows as to train the whole body or agonist/antagonist movements across a joint. This is a great compromise between time efficiency and effectiveness.

Again, these can be prescribed for sets/reps or time periods (I wouldn’t go less than 10 minutes for two exercises, as the volume ends up being too low).

Some common ways to pair movements include:

  • Upper/Lower pairing
    • Use either complementary pairing i.e. upper push/lower pull or similar pairing i.e. upper push/lower pull or vice versa
    • Pain management via both local tissue effects and/or central inhibitory effects
    • Develop whole body functional capacity
    • Enhance physiological buffer zone
  • Agonist/Antagonist pairing
    • Upper or lower push/pull (e.g. push up and row or squat and kettlebell swing/leg curl)
    • Ideal when local tissue factors are the dominant clinical feature
    • Pain management via both local tissue effects and/or central inhibitory effects
    • Develops local tissue capacity which can enhance the physiological buffer zone

Whole Body

I use Chad Waterbury’s definition of a whole body workout: each workout consists of at least one lower body exercise, along with an upper body push and pull.

(you can have two or more workouts as part of the program, to ensure you develop a variety of movements)

The benefits of a whole body workout start shifting towards central pain inhibitory mechanisms and developing the physiological buffer zone.

Again, you can program this based on sets/reps or time. With more exercises you have the option to perform straight sets, a combination or straight and alternating sets or a circuit format.

As a general rule, straight sets will bias local tissue factors slightly more, while alternating and circuit formats will bias work capacity/central factors slightly more.

I like whole body rehabilitation programs as they allow for work on both strengths and limitations simultaneously, which is good for compliance. We all like to succeed and do what we are good at.

They are also great options for in-season maintenance for athletes. Training 2-3 times per week allows the use of 6-9 key exercises, while other areas can be prioritised – i.e. tactics, skills, recovery (and work, family, social life etc).

Comprehensive

The comprehensive program, using the principles outlined in this manual [referring to our rehab manual] simply means taking one exercise from each category: upper body push and pull, lower body push and pull and core.

You can perform these in a circuit form, paired sets or straight sets depending on the desired outcomes.

This type of program trends more towards maintenance of capacity and physiological buffer zone, as well as ensuring central pain inhibitory mechanisms continue to function optimally.

Comprehensive programs are fantastic for the following scenarios:

  • End-stage rehabiliation of athletes before the return to play
  • Mid-to-end stage rehabilitation of non-athletes who are not otherwise active
  • Health-promoting effects of older people, who may be suffering from age related sarco and ostepenia, as well as reduced cardiac capacity
  • Simple preventative home exercise programs for sufferers of chronic low back pain
  • A way to engage sufferers of conditions like fibromyalgia in strength training (you can minimise the dosage and spread the loading across the whole body)

Conclusions

Rehabilitation is complex, but it doesn’t have to be complicated.

By having a set of different templates you can draw on for different scenarios, you can make your exercise prescription more systematic and efficient, leaving more time and brain power to think about and discuss the more human variables surrounding rehabilitation.

Things like goals, interests, barriers and facilitators to adherence and everything else that is important in holistic pain management.

Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

How To Build A Strong Back (And Why It’s Important)

Having a strong back helps improve your quality of life.

A strong back allows you to perform daily tasks with relative ease and is protective against injury.

The “back” isn’t an actual body part, but rather a descriptive term. In this article, it means the area from the base of the neck to the top of the pelvis.

Functionally, we can divide the back into two parts:

  • The lower back, which is primarily involved in lifting, carrying and supporting our upright posture
  • The upper back, which provides a foundation for the shoulder girdle and supports our head and neck

In a way, the back also encompasses the “core” and the “shoulder”, which is a good reminder that these are all labels that we give to the body – it functions as a whole, and the separation is only in the way we think about things.

So with that in mind, we can still use these concepts to help us build a strong back.

You don’t need expensive or fancy equipment. Muscles only respond to tension, which can be generated in a number of ways, with or without external weights

Barbells, dumbells, kettlebells, resistance bands, along with pull up bars and suspension trainers to leverage your own body weight are all fantastic ways to develop back strength, and of course, you have specialised machines that can help develop a strong back.

The key is to find an approach that works for your body and your situation.

Top Reasons To Build A Strong Back

  • The act of strength training is protective against back pain (1)
  • Strength training for the upper back was the best intervention for pain in desk bound office workers (2)
  • A strong back helps maintain your optimal posture (more on posture here)
  • The mid back is a common site for osteoporotic fractures – strength training prevents this (3)
  • After the legs, the back muscles are the biggest and strongest in the body, training them expends a lot of energy, helping maintain body composition and blood glucose levels (4)
  • Strong backs look good (don’t underestimate the importance of a positive self image)

Pull, Lift, Carry

There are 3 main actions you can perform with your back muscles:

  • Pulling actions, where you pull yourself towards something, or something towards you. Examples include chin ups, rows and climbing. These movements tend to develop predominantly upper back strength by working on the muscles the move the shoulder blades and arms.
  • Lifting actions, which are those actions where you pick something up (usually from the ground). Examples include deadlifts and power cleans.
  • Once you have picked something up, you can also carry the object for time or distance. Both lifting and carrying exercises develop both lower and upper back strength by working the muscles that stabilise the spine. They usually develop leg strength as well, so are very efficient exercises.

The Best Pulling Exercises

There are a variety of ways to train the pulling movement.

When you consider the freedom of movement the shoulder girdle has, it allows a high number of variations.

The Movements

The shoulder blade (scapula) has a number of ways it can move, but when it comes to pulling, the 3 we are concerned with are:

  1. Retraction: squeezing your shoulder blades together, as in when you perform a rowing action. Examples would be all the row variations in the world!
  2. Depression: pulling your shoulder blades down, as in when you pull yourself up to a bar/ledge. Examples would be chin ups and lat pulldowns.
  3. Upward rotation and elevation: when your shoulder blades turn upwards and raise, as in when you are pulling something in front of your body to your neck. Examples of these are upright rows, shrugs, high pulls, cleans and snatches.

For most people, I like body weight pulling exercises, like chin ups, inverted rows and climbs, though these are often very challenging and hard to scale down for beginners.

Where To Start

In the gym, cable rows and pulldowns, along with barbell and dumbell rows are the go to, with a large number of variation available via hand position, body angle and line of pull through the shoulder.

In practice, a $6 band from Kmart can be a great tool to enable you to perform pulling actions. Loop it around a post and pull it toward you. Loop it around your feet and pull it up. Loop it around a rafter/beam/tree branch and pull it down.

Do More Reps!

As a rule of thumb, pulling exercises are better as volume exercises, not intensity.

That is, perform a higher number of reps per set on average.

You can still load pulling exercises quite highly, but the combination of distraction force through the upper limb and ambiguous end point make it hard to do so as effectively as deadlifts, presses and squats.

Often Overlooked

One class of exercises that are often overlooked in both rehabilitation programs and fitness programs outside of the weightlifting/powerlifting world are shrugs and high pulls.

These train the upward rotation and elevation motion in the shoulder blades (shrugging), which strengthen the trapezius muscle.

A strong trapezius muscle supports healthy shoulder and neck function, but unfortunately, because many people with neck pain report a “tight” trapezius, these exercises were vilified. What was missed is that in these people, their trapezius feels “tight” because it is weak, and strengthening relieves their symptoms.

My Personal Favourites

So while my favourite pulling exercises are:

  • Chin ups (palms facing toward you) and pull ups (palms facing away from you)
  • Inverted rows (elbows high and elbows low)
  • High pull/upright row

In a perfect world, I would help all my clients develop competency and strength in these movements. But because I live and work in an imperfect world, and time, equipment and money are often limiting factors, the exercises I use most in clinical practice are:

  • Band pulldown
  • Band row
  • Band upright row

Deadlifts

The deadlift is a fantastic all-round back strength exercise. It also concurrently helps develop strong legs, particularly the posterior chain muscles, including the hamstrings and gluteals.

It involves picking up a weight implement (barbell, dumbell, kettlebell, etc) from the ground and then lowering it back down again.

There are countless deadlift variations, but my favourite is the barbell deadlift from blocks.

Rogue Metal Deadlift Blocks (https://www.roguecanada.ca/rogue-metal-pulling-blocks)

A close (equal) second is the trap bar deadlift and the kettlebell deadlift.

Why do I favour the barbell deadlift from blocks over other deadlift variations to build a strong back?

  • It allows us to infinitely and incrementally load the pattern, compared to kettlebells, which come in large jumps (usually 4 kg) and only go up to 48 kg in pro-grade style or (very large) 92 kg classic style.
  • We can control the range (rather than lifting based on the height of the weight plates) and ensure the movement is performed within a range that is safe for an individual’s mobility and strength.
  • It is better than a rack pull because the moment arm (from the centre of the bar to the load, not of the load on your spine) is larger (allows better leverage when starting the lift) and as a bonus, protects the bar.
  • Compared to the trap bar, the straight barbell requires a more bent over position, creating a large anterior shear moment on each vetebrae, which the back muscles have to resist, which develops high levels of strength in the spinal stabilisers.

The main downside to the barbell deadlift from blocks is it is more technically challenging/less intuitive than the trap bar or kettlebell deadlift. However, even though these are simpler, and some might argue more “functional” in that they require you to stand between the handle (like a wheelbarrow) or have the load between you (like lifting a heavy bag of fertiliser), I feel like they understimulate the back and posterior chain (relatively).

A second issue is equipment, while most gyms, and many clinics will have a barbell, not many have access to proper lifting blocks. A compromise is to use aerobic steps or weight plates, though they are just that, a compromise.

In reality, you can use a variety of deadlift variations, it doesn’t really matter, as long as you are developing the strength to pick things up from the ground.

Typically, deadlifts can be performed heavy for lower repetitions, or lighter for higher repetitions. They lend themselves well to both applications.

Not Quite Deadlifts

There are a number of exercises that have a similar pattern to the deadlift – the hip hinge movement – that aren’t quite the deadlift.

Think of exercises like:

  • Good mornings
  • Kettlebell swings
  • Back extensions
  • Reverse hypers

These are all great exercises.

They definitely have a place as deadlift alternatives or additions to deadlifts.

The reason I list them as a second tier, is because for most people, I seek maximum training economy, and with that in mind, deadlifts are more than enough stimulation. I would mostly use alternatives when deadlifts are not appropriate:

Loaded Carries

Loaded carries are an under utilised exercise in both performance and rehabilitation.

They are simple movements, but are definitely not simplistic.

Loaded carries can be performed in a few ways:

  • Bilateral loading
  • Unilateral loading

And with the load in different positions

  • By sides (farmer’s walks, suitcase carries)
  • In the rack position (with kettlebells or a barbell)
  • Yoke carries (across the shoulders)
  • Overhead

The most important thing to ensure with loaded carries is to retain postural integrity. The idea is to train dynamic stabilisation under load, not test your limits of how far you can carry a heavy object.

A good guideline is to work with 75% of your bodyweight for farmer’s walks. This might sound light for experienced athletes, but remember, we are trying to build strength, not test it. Building strength can be done with sub-maximal loads, and it allows for faster recovery and better movement patterns.

Conclusions

Pulls, deadlifts and carries are more than enough to build a strong back.

However, there are many other variations of exercises that can be used too.

I’m not in the business of vilifying movements, and given the low activity levels of the majority of Australians, almost any movement is good movement.

Whichever movements you choose, for most people 2-3 times per week is the optimal frequency to develop strength, while the exact amount volume of work you do is individual, the idea is to do more over time.

What I have listed here are the best back exercises for the majority of people, the majority of the time.

While in theory, structured exercise is not essential for health, when it comes to developing a strong back, the simple truth is that the majority of Australians are not physically active enough to develop and maintain adequate strength throughout their lifetime, and so need a structured program to make up for it.

Do you need a stronger back?

If you feel like you could benefit from increased back strength and a holistic exercise program, then contact me to arrange a consultation. This can be done in person or online, depending on your location.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

 


 

 

 

References

(1) Exercise for the Prevention of Low Back Pain: Systematic Review and Meta-Analysis of Controlled Trials

(2) Effects of stretching exercise training and ergonomic modifications on musculoskeletal discomforts of office workers: a randomized controlled trial

(3) Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: novel early findings from the LIFTMOR trial.

(4) Effects of Different Modes of Exercise Training on Glucose Control and Risk Factors for Complications in Type 2 Diabetic Patients

Why You Should Choose Conservative Health Care

,

You can’t cut out pain. – every *good* orthopaedic surgeon ever

Despite what we know about pain, many people are subjected to poor medical management for their pain on a daily basis.

From the recommendations of medications that don’t work for certain conditions (ahem, anti-inflammatory drugs and low back pain), to expensive courses of passive therapies that have extremely low effect sizes.

Not only do these treatments not work very well, they are is an enormous waste of everyone’s resources. To make matters worse, many of these management strategies are not benign, meaning they have the potential for negative side effects.

When it comes to poor medical management, over the counter medications and ineffective passive therapies are the (very small) tip of the iceberg. Many costly, and potentially dangerous drugs, invasive therapies like injections, nerve blocks and the “grand-daddy” of them all, surgery all carry high risk profiles and for very small benefit, especially over the long term.

It’s right about now that I should add some moderation to this post:

I’m not saying these treatments are completely worthless all the time. In fact, I have had many patients who have benefited from the right prescription or surgery over the years.

What I’m saying, is that these treatments often come with big costs and risks that are not fully disclosed when they are recommended (although nearly every surgeon does a better job at explaining the risks of their treatments to patients, many still overplay the benefits or don’t fully explain the alternatives).

With this in mind, the sleeping giant in the treatment of most painful problems, especially those involving the musculoskeletal system is good conservative health care.

I emphasise the good, because there is so much bad out there.

No, I’m not trying to be negative and put down other health professionals. I am simply stating, that based on my experiences with patients (and supported by research), many have not had adequate conservative care to begin with, which is how they’ve ended up with chronic conditions in the first place.

What Is Conservative Health Care?

Conservative health care is based around interventions designed to avoid radical medical therapeutic measures or operative procedures. 

They are typically lower in cost than more aggressive treatments, which a much safer risk profile.

The downside is that some conservative treatments don’t have a large effect size, and many work in general, not specific ways.

Some examples of conservative health care include:

  • Education, advice and reassurance
  • Lifestyle changes
  • Dietary changes, including supplementation
  • Exercise based interventions
  • Physical/manual therapy
  • Certain medications

When Should You Seek Out Conservative Health Care?

Conservative health care is not appropriate for all health problems.

Serious and life threatening conditions typically need more aggressive and/or invasive treatments. Examples of such conditions include major infections, cancer, organ diseases and major trauma (though there are many more).

When conservative health care is most optimal, is when a condition is chronic and stable, or progresses slowly, when the condition is self-limiting (i.e. it will resolve with time, and symptomatic management is all that is required) and when the condition is non-specific (it can’t be attributed to a single cause), like many low back pain presentations.

Usually, a general practitioner will be able to advise you when conservative options are suitable, so that’s often a good place to start.

Conservative Treatment For Pain

Pain is the number one reason people consult their GPs, however, a lot of pain is very poorly managed from the begining, leading to the progression towards chronic and more debilitating pain.

This is where I feel that conservative management can really shine.

Almost every chronic condition will improve to some degree from improving your health generally.

Additionally, many chronic pain presentations will benefit just as much, if not more in the long run, from good conservative management.

Unfortunately, many people miss out on receiving good conservative care when they need it most, leading to them needing/wanting more aggressive treatment options when their condition has progressed.

The Benefits of Conservative Health Care

Conservative health care has a number of benefits for all parties involved: patients, practitioners and 3rd party payers (insurance companies, governments etc).

One of the biggest benefits is economic.

Let’s take chronic low back pain as an example, because it is so prevalent, and so widely researched.

The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.

When we look at the costs, most people intuitively think of the cost of treatment (consultations, investigations like imaging, medication etc), however, the bigger cost is the indriect cost, that is the cost to society and the individual of lost income, productivity and quality of life as a result of their condition.

While the direct costs of chronic conditions is around A$9 billion annually, the indirect costs are a staggering A$54 billion annually!

With such high costs, you’d think that prioritising excellent conservative care from the outset would be high on the agenda for all involved.

Unfortunately, many clinicians do not follow the clinical care guidelines which are developed by compiling the best evidence from researchers around the world. In fact, only 20% of low back pain patients received care inline with the guidelines.

These guidelines are designed to ensure the best possible management of each condition, yet with only one in five people getting treatment based around them, many are missing out and going on to develop chronic pain, which ends up costing them in time, money and quality of life.

Other benefits of conservative health care include:

  • Safety – by definition, most conservative health care is low risk.
  • Availability – there are typically many more health professionals able to deliver conservative health care than specialists who deliver more invasive treatments.
  • Sustainability – conservative approaches can typically be maintained over the long term, which can help manage chronic conditions.

What stops people getting good conservative treatment?

I believe that most of the time, most people are doing the best they can. As a result, the lack of implementation of clinical guidelines for conservative care is not down to any one factor, but here are a few:

  • Market forces – funding for public health services is always stretched, so GPs cannot spend adequate time educating patients. Private practice clinicians are often limited in the number of times they can see someone due to a patient’s ability to afford treatment.
  • Expectations – patients often want to be “fixed”, not understanding, or wanting to participate in more active management for their conditions.
  • Practitioner knowledge and skill – most health practitioners are skilled in diagnosis and treatment, not in facilitating behavioural change. This makes it hard to create long term, empowered change.

With this in mind, we can see the challenges that need to be overcome to offer the best available conservative care.

What is needed to improve conservative treatment?

  1. Government and insurance companies need to appreciate the long term cost savings conservative care offers, and fund it accordingly. If a surgery costs $20,000 spread across direct and indirect costs, and that surgery could have been prevented by 2 years of physical/exercise therapy, then even at $100 per session, twice per week, you are coming out at break even. However once you add in the rehabilitation costs of surgery, and the costs of the increased risk, the physical therapy option is actually cheaper.
  2. Patients need to take responsibility for their thoughts and actions. Yes, circumstances can affect everyone, which can make life harder and less fair for some, however, taking 100% responsibility for how you respond and act will mean that you are in the best frame of mind to improve your situation and your condition.
  3. Educational institutions need to adapt to the changing demands on healthcare and focus more on communication and behaviour change. Simply increasing the awareness of this important skill will lead to those interested healthcare practitioners pursuing further education.
  4. Health practitioners must accept that they can always improve, and seek out ways to develop their skills to better serve their patients. This includes seeking out appropriate continuing education, but it also means enhancing their networks and their ability to utilise these networks to benefit their patients.

The Big Two

Of all these factors, the two most important are economic and cultural forces.

Money is always an influence on how we make decisions, and many people simply don’t have the financial freedom required to pursue optimal conservative care, especially privately.

While there are always those who are living on the edge, and literally have no room in their household budgets for anything about the essentials of living (housing, food, transport and utilities), there are many more who claim that health care is too expensive. Yet these people walk around with the latest iPhone on a high monthly plan, or drink/smoke/gamble regularly. For these people, who may be on average incomes, it is simply a matter of choice and priorities*.

This is where culture becomes important.

Our culture in Australian is heavily influenced by commercial interests.

Unfortunately, there is a lot of money to be made in selling treatments for conditions that offer a simple solution to a person’s health problem.

Whilst they appeal to our emotions, simple solutions are usually inadequate for complex problems.

So when you propose a long term course of conservative care, which involves active participation by patients, it is often a tough sell.

It is made even tougher by the massive marketing budgets pharmaceutical companies and medical device companies have. They use these to influence our culture.  Every night on TV there are commercials for different types of pain medications. Ironically, if most people spent just 30 minutes less watching TV, and decided to go for a walk instead, they probably wouldn’t need them anywhere near as much.

A Different Perspective

If instead of thinking in terms of expense (cost and time/energy), you changed focus to investment, then immediately you have changed your perspective on health.

When you invest in a term deposit, at the end of the term you have more money than when you started.

Conservative health care, done properly, is an investment.

Yes, you are spending time, money and energy to change your health, which has an initial up front cost. But, by the end of the treatment program, you should have improved health, reduced pain, better function and an overall better quality of life.

Get more years out of your life, and get more life out of your years.

These improvements can be thought of as your return on investment. Like a term deposit, conservative treatment is mostly safe, offers fairly predictable outcomes and is overall, low risk.

Once you have restored your health, the idea is to maintain it (just like you would with wealth). Usually this means you need to continue your healthy habits which you established during treatment.

A final word on perspective; if you are in debt, you must pay back your debt before you can invest. The bigger your debt, the more work and time it takes to repay. The same school of thought applies to health. While things can change quickly, true healing from chronic conditions, or even severe acute conditions, takes time.

If that puts you off, think about it like this: time will pass, regardless of what you do or don’t do. If you do nothing, you will be in the same, if not worse situation in a year or ten.

Conclusions

Conservative care is extremely important from both a public health and individual perspective. Delivered optimally, it saves money, improves outcomes and reduces the need for interventions with higher side effect or risk profiles.

There are some barriers to delivering good conservative health care at the population level. On an individual level, the two most important variables can usually be overcome.

If you are a patient: when you are seeking out a health care provider, discuss long term strategies and look for providers who will incorporate an active management plan.

If you are a practitioner, you should look to improve your communication and behavioural change skills. Telling someone what to do isn’t good healthcare. Guiding them through the process of how to do it is.

 

Nick Efthimiou Osteopath

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

Notes

*For those who are truly struggling, most universities with allied health programs have student teaching clinics. These allow students to provide supervised care at reduced costs. In special circumstances, the fees can even be waived. Bottom line, no matter your circumstances, if you are really set on helping yourself, you can find a way.

References

(1) Medibank: Chronic pain costs economy more than $22bn a year

(2) Pain drain: the economic and social costs of chronic pain

(3) The burden of musculoskeletal conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011

Movement Quality, Health and Fitness

When it comes to movement quality and fitness, nature had it right all along.

Developing movement quality before fitness is hard-wired into us.

We crawl before we walk.

We walk before we run.

First we develop the quality and control of movement. Then we start doing more of it, which develops our capacity of movement (fitness).

This is the pathway that humans have followed forever, until recently.

Now, around about the age of 5, we send children off to school, where they learn to sit still. We even give out stickers to the kids who do it best.

At this age, things aren’t too bad though. We have about 4 years of movement “training” under our belts compared to 1 year of sitting.

Fast forward to age 10, and that ratio is now 4:6, not great, but still not too bad.

Let’s accelerate to 18, when most kids, now young adults are graduating from high school.

They’ve now been sitting for the majority of their day for 14 of their 18 years.

Many would have played sports recreationally, and suffered injury as a result.

Can you see the problem?

And we are only looking at an 18 year old, who for all intents and purposes, is in the peak of youth, and physical potential.

What happens when we hit 40, 50 and beyond?

Fitness First, Then Injury?

You’d think getting fitter and healthier would be easy. Our bodies are designed to thrive after all.

The problem is, people start out with poor general health.

Think of the average person over 30. They are likely over stressed, possibly anxious or depressed. Body functions like their digestion, elimination and breathing are dysfunctional. Their physiology is impacted by poor sleep quality and quantity, and abnormal light exposure. And, they aren’t moving at all, with the average Australian clocking in at a measly 4000 steps per day. (1)

For the average person who decides to take action and make themselves healthier, it’s an uphill battle before they’ve started.

So when they start exercising with intense, and often short term programs, they are actually adding more stress on to an already stressed body. Combine this with a restrictive diet, and the situation becomes even worse.

It doesn’t take a genius to work out that this might be too much.

Get Healthy First

What should you do instead?

Before you jump head first into an intense exercise program, commit to walking*.

Sounds too easy?

That’s the point.

If you walk daily, you experience a myriad of health benefits that compound. This sets you up for more intense work in the future, if that’s your goal.

Walking is sustainable, so you can do it for the rest of your life (and you should).

You can walk outside, which is ideal, but if weather or safety doesn’t permit, you can walk on a treadmill.

The whole point of starting with walking, is that it is supposed to be mentally and physically achievable. Success breeds success.

All this walking will:

  • Reduce your stress levels
  • Improve your body composition
  • Improve your cardiovascular health
  • Allow you some “down time” in our constant “on” world

This in term will help you sleep better, so your mood improves as your brain and hormones start to balance out.

As a result, it becomes easier to improve your diet, because you aren’t fighting against a stressed out and fatigued brain that wants quick fixes of sugary, salty and fatty convenience foods.

The principles of a healthy diet are simple. Changing your diet is not, because it is about changing your habits.

For most, the best approach is to work with a dietitian or nutritionist. Because in most cases, it isn’t a lack of information that stops people making change. Everyone knows they should eat more vegetables, but most don’t eat enough.

If you can’t, or don’t want to, you can try and change yourself.

For the best chance of success, you want to change one thing at a time. This is why I recommend walking first. It establishes a healthy habit which can have a snowball effect.

With nutrition, change one meal at a time.

Check out the Australian dietary guidelines. Then, starting with breakfast, look to improve your diet one meal at a time. Once a breakfast becomes a healthy habit, move on to lunch and so on.

If you can start walking regularly, and get your diet in order, you are more than half way to a healthy lifestyle that minimises your risk of all kinds of diseases.

This also enhances your quality of life, which is often overlooked – it’s not just how long you live, but how well you live.

This process might take time. Months, even years for some. So it is important to learn how to relax, both physically and mentally.

You can’t keep putting stress upon stress and expect good results, let alone good health.

Learning how to relax physically and mentally allows your body to recover, which is when your body repairs and your health improves.

Everyone is different, but I find things like having a spa/steam, getting a massage, going for a walk and reading a book great ways to relax either alone, or with family/friends.

Again, the challenge here is more mental, the feeling of being in a “rush” to get fit.

It’s funny, because usually this rush is felt after years of doing nothing. Hence the appeal of “12 week programs”. A better approach would be a “12 month program”, but often this is felt as being too slow. The same people who feel 12 months is too long will undoubtedly be saying “wow, that year has just flown by” come December.

The simple act of getting healthier will improve your fitness, but trying to get fit when you aren’t healthy won’t improve your health, and can often harm it.

Then Move Well

Movement quality, like health, is often skipped over in the chase for capacity.

Like skipping the “get healthy” stage, skipping movement quality is a recipe for future injury.

The problem is, movement quality is hard to measure.

Doctors will be able to tell you whether you are healthy enough to exercise with intensity, they won’t be able to tell you if you are ready for a loaded squat or running.

There is no one way to move well, but there are common features on moving well. Think of watching a high level dancer. It likes smooth, controlled, almost effortless. They are moving well.

Moving well is a lifetime endeavour (are you sensing a theme?), but to start out, you can perform some simple tests to see what your starting point is like.

  • Can you touch your toes?
  • Can you reach over and under your shoulders and touch your fingertips, without straining?
  • Can you squat to below parallel without your heels rising or losing your balance?
  • Can you stand on one leg with your knee lifted above your hip for more than 10 seconds?
  • Can you perform a plank for 30 seconds? What about a push up? What about 5?

Most of these movements are simple, yet involve a lot of physical capability. If you can’t perform them, are you ready to be running for 30 minutes or performing “functional high intensity workouts”?

If you lack some fundamental movement quality, you don’t have to put your fitness on hold – remember, improving your health, in this case your movement quality, will improve your fitness.

Improving your movement quality doesn’t mean you don’t get to use load either. Load can often be corrective.

But it does mean identifying why you aren’t moving well.

If you have a mobility issue, simply adding load won’t resolve it. Likewise, if you aren’t moving well because of impaired sensory function, you will want to address that.

Moving well is a continual process, but after you have established a healthy base, you will likely want to build capacity.

Next, Develop Your Fitness

You need fitness too.

Especially later in life, when having low physical capacity becomes problematic.

The key though, is to build your fitness/capacity before you get older. The earlier you start, the better, but it’s never too late. Never.

How much fitness, or capacity do you need? Enough to do what you need to do, with a little left over.

This left-over is termed the physiological buffer zone (2).

It is basically your margin for error.

The bigger your buffer zone, the more you can do without breaking down, getting injured or ending up in pain.

A favourite study of mine showed that in US Marine recruits, those with low Functional Movement Screen (FMS, a simple screen to assess movement quality) scores and a low 3 mile run time had a much high probability of getting injured during physical training (3).

Both the run and the FMS were predictive, but the combination was much higher.

This suggests that moving well, or being fit alone is beneficial, but moving well *and* being fit has a compounding effect.

High Training Loads Protect Against Injury

Lots of recent research in sports science is showing that high training loads are protective of injury. (4)

This means, the more work you do, the more resilient you become.

However, how you get to those high training loads matters.

If there is a sudden jump in workload, that is a big risk factor for injury, so you have to build up slowly. If you look to fit people for inspiration, and try and model what they are doing, you are failing to take into account that it likely to them years to achieve their current level.

Monitoring your workload is important, so that you can know when to push and when to back off. A good personal trainer or exercise physiologist can help you, and will accelerate your progress.

Conclusions

This is a lifetime process.

If you do it correctly, focusing on health as your priority, then you set yourself up for a lifetime of benefits.

It’s definitely not easy.

You will have periods where you feel like it is all clicking.

You will have periods where it all seems so hard.

But, if you establish healthy habits, then you can continue with the behaviours that benefit you no matter what life throws at you.

 

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 


 

 

References

*If you are unable to walk due to disability, then a similar low intensity replacement is ideal, but for able bodied people, walking is the best option.

(1) Australian Daily Steps

(2) Movement Reserve: Enhancing the Physiological Buffer Zone

(3) FMS and Aerobic Fitness Predict Injury

(4) Monitoring Athlete Training Loads: Consensus Statement

(5) Andrew Read and Greg Dea seminar, September 2016: Advanced Program Design

How To Build Strong Legs (And Why It’s Important)


Having strong, well balanced legs are a key component of having a healthy, high functioning body.

Our legs are anatomically suited to producing both high levels of force and for walking and running long distances.

This means we need to develop both functions – strength and stability through full range of motion along with the endurance to be able to walk and/or run for distance.

You can build strong legs using expensive gym machines, time tested free weights, with your body weight or using a combination of all three.

Lots can go wrong with your legs:

  • Ankle sprains are the most common lower limb injury (1)
  • Knee injuries are common in athletes and ACL tears are one of the most debilitating sports injuries you can suffer, with females especially susceptible (2)
  • Additionally both the patellar and Achilles tendons are common sites for tendinopathies
  • The knee and hip are most common sites for osteoarthritis (3)

Strength training can be used to both prevent and manage all of these conditions, but done improperly can be a cause of injury itself.

Benefits of Strong Legs

Some of the specific benefits of developing strong legs include:

  • You live longer (4)
  • Greater independence as you age (4)
  • Decreased lower limb injury risk (5)
  • Decreased risk of falls (6)
  • Improved endurance performance (7)
  • Improved speed and power
  • Increased lean body mass – decreased risk of metabolic diseases (8)
  • Improved rehabilitation outcomes after injury (9)
  • Strong legs look good

The 3 Stances

Before we go into how to build strong legs, it helps to understand the different ways we can load the lower body, and the different effects each has.

As humans, we can essentially adopt 3 foot positions.

Most people will favour one side when standing, accelerating, jumping and landing, or just getting through the household chores, which can develop functional asymmetries.

Functional asymmetries are side to side differences in mobility or stability that are not associated with your body’s structure. Functional asymmetries are a modifiable risk factor for future injury (10).

To minimise functional asymmetries and develop strong, well balance legs, requires working in each of the 3 stances.

Bilateral Stance

Bilateral stance involves both feet being on the ground in the same horizontal plane, without movement. It is the most stable, and hence strongest position, and we can lift the heaviest loads in bilateral stance.

Split Stance

In a split stance, both our feet are on the ground, but in a different horizontal plane. Split stance requires the leading leg to be stable through the hip and knee while the trailing leg must display mobility at those joints. You see a split stance being adopted when we need a blend of stability and mobility, for example, if you were chopping wood or throwing a ball.

Single Leg Stance

Single leg stance is displayed when we have one foot completely off the ground. This can be for a moment, as in when we are running, or when we need increased mobility, like when we reach for something on the ground.

Single leg stance requires high levels of stability in the stance leg and trunk to allow you to express the mobility it facilitates.

Use Single Leg Exercises First

Before undertaking a strengthening program for your legs, it’s wise to have an assessment with a qualified and experienced professional.

A good assessment acts like a road map – showing you where you currently are and where you need to go to improve your function and strength.

Most people will tend towards either being stiffer and more stable or flexible and less stable. Typically, we will see the most benefit from developing what you lack – so a stiff person will benefit from developing flexibility and mobility and vice versa.

If the assessment reveals you have a functional asymmetry, then a good place to start your leg strength program is with single leg exercises.

Single leg exercises are a great way to develop the required flexibility and stability at the same time, and help balance out differences between each leg that may have developed over time.

It’s best to start with a split stance, which gives you a nice blend between stability and mobility, versus true single leg stance, which requires stability levels beyond what most possess without training.

Examples of split stance exercises are:

  • Split squats (where the feet remain in contact with the ground throughout)
  • Lunges (where one foot leaves the ground momentarily)
  • Step ups

You can build tremendous strength with single leg exercises alone, but it is still important to develop strength in a bilateral stance as well, in particular with the squat pattern, which is a fundamental human movement.

Squats For Total Body Strength

The squat is simply the best lower body exercise you can do, if you can do it properly.

Squatting demonstrates ankle, knee, hip and spine mobility and trunk stability in the most fundamental human movement pattern – it’s how we first get up from the ground to be able to walk.

It is well worth the time and energy to develop your ability to squat well through a full range of motion.

For rehab patients, I like to teach the squat from the bottom up, which is after all, how we first learnt it. I find that by getting someone into the bottom position of a squat comfortably, the rest takes care of itself.

Surprisingly, my older patients do really well with this method as well, as they are already close to the ground, the risk (and fear) of falling is much lower. Once they are familiar with the bottom position, it is a matter of getting strong enough to stand up.

The most common issues with the squat tend to be at the ankles, followed by the hips.

To work around this, you can begin squatting with your heels elevated while you work towards an unassisted squat.

Conclusions

Strong legs are for more than just fitness fanatics, they are crucial to living a healthy and active life.

It’s important to not only build strong legs, but develop balance and mobility that allows you to move freely.

To do this, it’s important to have an assessment and develop a plan that meets you where you are at, and takes you where you need to go.

While structured exercise is not essential for health, when it comes to developing strong legs, the simple truth is that the majority of Australians are not physically active enough to develop and maintain adequate leg strength throughout their lifetime, and so need a structured program to make up for it.

Not all programs are designed equally though, so for the sake of safety, efficiency and effectiveness, it pays to seek out qualified professionals to help guide you, especially in the early stages of building leg strength.
Nick Efthimiou Osteopath

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

References

(1) Incidence of Lower Extremity Injuries in US Emergency Departments

(2) Epidemiology of Lower Extremity Injuries in US High School Athletes

(3) Epidemiology of Osteoarthritis in Australia

(4) Leg Strength and Physical Function In Older Adults

(5) Strength Training Reduces Injury Rate in Elite Junior Soccer Players

(6) Effect of Leg Strength on Falls and Balance of the Elderly

(7) Effects of Strength Training on Endurance Capacity In Top Level Athletes

(8) Increased Leg Strength per Body Weight Associated with Improvements in Metabolic Syndrome in Japanese Men

(9) Merits of Exercise Therapy Before and After Major Surgery

(10) Prediction of injury by limited and asymmetrical fundamental movement patterns in american football players